Main outcome measure - Associations between
circumcision status and past or present diagnoses of STDs
including HSV-2 serology and clinical pattern of genital
herpes.

Results - 185 (62%) of the men were circumcised
and they reported similar ages, education levels and
lifetime partner numbers as men who were uncircumcised.
There were no significant associations between the presence
or absence of the male prepuce and the number diagnosed
with genital herpes, genital warts and non-gonococcal
urethritis. Men who were uncircumcised were no more likely
to be seropositive for HSV-2 and reported symptomatic
genital herpes outbreaks of the same frequency and severity
as men who were circumcised. Gonorrhoea, syphilis and acute
hepatitis B were reported too infrequently to reliably
exclude any association with circumcision status. Human
immunodeficiency virus infection (rare among heterosexual
men in the clinic) was an exclusion criterion.

Conclusions - From the findings of this study,
circumcision of men has no significant effect on the
incidence of common STDs in this developed nation setting.
However, these findings may not necessarily extend to other
setting where hygiene is poorer and the spectrum of common
STDs is different.
(Genitourin Med l994;7O:317-320)

Introduction

It has been suggested that uncircumcised men are at higher
risk of certain sexually transmissible diseases (STDs), in
particular genital herpes,1,2
gonorrhoea,1 syphilis,1 human immunodeficiency virus type 1
(HIV-1) infection,3
candidiasis1,2 and
chancroid.3 The evidence for
male circumcision protecting against most STDs is
tentative4 but is strong for
chancroid and candidal balanoposthitis (though not
necessarily subclinical yeast infection5). In some populations where chancroid
and syphilis may be the common causes of genital ulcers,
these ulcers and the uncircumcised state of the men (both
independently and synergistically) appear to be major risk
factors for the female to male sexual transmission of
HIV-1.3 The uncircumcised penis
is hypothetically at increased risk of STDs because of larger
surface area, thinner epidermal barrier, more opportunity for
epithelial microtrauma and the warm, moist niche under the
foreskin favouring the persistence of fastidious
microorganisms. However, none of these hypotheses has been
proven. We sought to determine any effect the presence of a
male foreskin may exert on the acquisition of common STDs by
heterosexual men attending an STD clinic and also its effect
on the clinical manifestations of herpes simples virus type 2
(HSV-2) infection.

Subjects and methods

A sample site of over 270 was calculated to determine a
two-fold risk of serological evidence of HSV-2 for
uncircumcised men with 80% power at the 5% level. However,
this calculation was based on an expected HSV-2
seroprevalence of about 30% for heterosexual men detected in
a 1985 survey at the same clinic (AL Cunningham; unpublished
data).

The subjects were 300 consecutive heterosexual male
patients who saw a particular clinician (IB) and required
venopuncture for any other purpose at the Sydney Sexual
Health (previously STD) Centre, Sydney Hospital, between
December 1990 and May 1991. Over 95% of the men were
Caucasian with the bulk of the remainder of Asian origin. The
subjects were representative of the general clinical load of
exclusively heterosexual men at the Centre: their reasons for
attendance or diagnosis at the time of consultation are
outlined in Table 1. HIV-1 infection is rare among
heterosexual men attending the Centre6 and, as HIV-l infection may alter the
natural history of other STDs, it was an exclusion criterion.
Homosexually active men were also excluded because anal
infections could have confused the objectives of the study.
The aims of the study were explained to all subjects and
signed informed consent obtained. There were no refusals. A
data collection form with an anonymous identifier code was
completed by the clinician and an extra five milliliters of
blood was collected for this study. The data collected
included age, level of education, circumcision status
(confirmed by physical examination), past history of genital
herpes or symptoms suggestive of genital herpes (undiagnosed
genital ulcer or recurrent genital lesions/itches),
nongonococcal urethritis (NGU), genital warts, urethral
gonorrhoea, syphilis and acute hepatitis B, as well as
reported lifetime number of sexual partners (women with whom
they had had vaginal intercourse). For the analysis, current
and past diagnoses of STDs were combined for each subject.
All STDs had been diagnosed by a physician, mostly at the
same clinic. The diagnosis of genital herpes was by cell
culture except for the current visit where the diagnosis was
on clinical criteria (the delinked anonymous study design
precluded incorporating current HSV culture results).
Similarly urethral gonorrhoea was diagnosed by culture except
for the current visit where the diagnosis was based on
clinical findings plus characteristic gram negative
intracellular diplococci on a urethral smear. NGU was
diagnosed by clinical picture (discharge/dysuria) and
microscopy of a distal urethral smear (5 or more polymorphs
per oil immersion field). Genital warts were a clinical
diagnosis. All syphilis cases required confirmation by
specific treponemal serology (Treponema pallidum
haemaglutination assay and fluorescent treponemal antibody
test). The diagnosis of acute hepatitis B required both an
acute hepatitis illness and laboratory confirmation.

Those subjects who had a history of genital herpes were
asked to grade the severity of their initial episode ("mild",
"moderate", or "severe"), and estimate the number, and
similarly grade the severity of any recurrences in the
previous 12 months.

The serological analyses for HSV were performed at the
Virology, Department Centre for Infectious Diseases and
Microbiology, Westmead Hospital in Sydney on an anonymous and
blinded basis. As described elsewhere,7 sera were screened for total HSV
antibody by a complement fixing antibody (HSV-CFA) test.
Positive specimens on HSV-CFA were then subject to an
indirect IgG enzyme immune assay (EIA) specific to the 92 kDa
HSV-2 glycoprotein G (gG-2).7
All 15 randomly selected sera that were positive for HSV-2 by
EIA testing were confirmed by Western blot.

Results

One hundred and eighty five (61.7%) of the men were
circumcised and 115 (38.3%) were not: this was not age
dependent (table 2). The associations between male
circumcision status and demographic, behavioural and STD
variables of the study group are summarized in Table 2. None
of these variables approached significance at the 5% level.
Though gonorrhoea, syphilis and acute hepatitis B were
reported too infrequently to determine any association with
the subjects circumcision status, histories of genital
herpes, serological evidence of HSV-2 infection, genital
warts and NGU were common and no distinct trends emerged.

Circumcised and uncircumcised men with previously
diagnosed genital herpes reported a similar duration since
the initial episode and similar frequency and severity of
recurrences in the preceding 12 months (Table 3). While there
was a trend for more uncircumcised men to describe their
initial genital herpes episode as severe and for circumcised
men to describe it as moderate the difference was not
significant.

Discussion

In this clinic-based prospectively
collected survey we found no association between male
circumcision status and STDs that are common in our
population. Perhaps importantly, our study group was
relatively racially homogeneous, lack of circumcision was not
a marker of lower socioeconomic status (using the index of
education level; Table 2), and we controlled for a
major parameter of sexual behaviour (lifetime number of
sexual partners). We did not investigate the relationship
between the presence of a prepuce and candidal
balanoposthitis as we regard the causal relationship as
proven. lack of circumcision is probably also a risk factor
for chancroid but this condition was rare in our population.
Similarly syphilis, acute hepatitis B and gonorrhoea were so
uncommon among heterosexual men attending our clinic that we
were unable to exclude any potential association. HIV-1
infection was an exclusion criterion for the study.
Symptomatic genital herpes and serological evidence of HSV-2
infection were both common in our population. We previously
reported on the risk factors for HSV-2 seropositivity in this
study group.8 On multi-variate
analysis the risk factors for HSV-2 infection were lifetime
number of sexual partners, lower level of education and
(marginally) a history of sexual contact with a women with
genital herpes.8 In the present
analysis, circumcision status did not correlate with a
history of genital herpes, recurrent genital ulcers or itches
(which might have represented undiagnosed herpes), or
serological evidence of HSV-2 infection. As an unexpectedly
high proportion (two thirds) of our study group were HSV-2
seropositive it would not have been possible to demonstrate a
two-fold protective effect for circumcision. Nevertheless no
trend toward protection was apparent (Table 2).

A previous Australian study which relied on the culture
diagnosis of genital herpes did find a correlation between
symptomatic genital herpes and lack of circumcision.1 However this study did not quantify
sexual partner numbers or other parameters of risk. Another
possible explanation for this finding in the previous study
might have been that men with intact foreskins harbouring
HSV-2 may be more symptomatic and thus be more likely to
present to a clinic. However we found that men who were HSV-2
seropositive were no more symptomatic than circumcised men,
nor were their lesion recurrences significantly more frequent
or severe. As only a limited number of our study subjects
were symptomatic, a larger study would be needed to exclude
the possibility that uncircumcised men suffer more severe
initial episodes of genital herpes.

Previous studies of the effect of circumcision status on
genital warts have produced conflicting results. In more
heterogeneous populations lack of circumcision has variously
been reported as making symptomatic genital warts both
more1,9,10 and less11 common. We found it exerted no
effect. One retrospective study found that circumcision
status affected the distribution of warts on the penis.
Uncircumcised men were more likely to present with distal
lesions and circumcised men with proximal lesions on the
penis.12 We did not investigate
this issue. We are unaware of any study to date that has
attempted to correlate circumcision status with subclinical
HPV infection.

We determined no association between circumcision status
and a history of NGU or gonorrhoea. In the case of gonorrhoea
this may have been because this was uncommon in our
population: the slight trend was for the presence of a
foreskin to be "protective". A previous large retrospective
American study found no association between gonococcal
urethritis and circumcision status.13 In the same American study it was
found that circumcised men were 1.65 times more likely to
present with NGU than uncircumcised men (95% CI; 1
.37-2.00).l3 The authors
hypothesized that the physical presence of the foreskin may
mask the symptoms (typically milder than gonorrhoea) of NGU.
The difference from our study could be explained, at least in
part, by the fact that our study group had a much lower
threshold for seeking medical attention. The majority (Table
1) were asymptomatic and had presented for STD screening.

A recent South Australian study found that uncircumcised
men were independently at increased risk of current diagnoses
of both chlamydial and gonococcal infection (odds ratios of
1.3 and 2. 1 respectively) on multi-variate analysis
factoring in "multiple partners in the previous month.14 However, in a separate report on the
same sample,1 being
uncircumcised was also a risk factor for pediculosis pubis
(OR 1.5)-a notion that lacks plausibility. In the latter
report,15 being uncircumcised
was protective for genital warts and had no significant
effect on the risk of genital herpes.

Only about 3% of the Australian male population would have
religious reasons for circumcision. British workers have
speculated that only another 1-2% would have unequivocal
medical reasons for circumcision later in childhood, usually
balanitis xerotica obliterans (leading to true phimosis) and
possibly recurrent balanoposthitis.16 Much of the public rhetoric in
Australia ("We don't cut babies' ears off because they need
to wash behind them") is opposed to neonatal circumcision and
a health service study had indicated that circumcision had
become less common in Australia by 1983.17 Thus we were surprised to find that
62% of our study population was circumcised and that younger
men were just as likely to be circumcised as older men. A
comparable overall circumcision (63%) rate has been reported
from a South Australian STD clinic,18 though in that clinic younger men
were slightly less likely (55%) to have been circumcised.
Some British authors
have deplored circumcision rates in that country of 7% and
describe the majority of these procedures as
"unnecessary".16 As Australia
enjoys close cultural links with Britain these dramatically
different male circumcision rates imply that cultural
determinants of the procedure are amenable to the influence
of the "medical gatekeepers". Notably, Australia has a
largely fee-for-service system of payment for health
services.

While the universally negative findings of the current
study should contribute to the current debate on the need for
male circumcision, they cannot be automatically extended to
developing societies. In other settings, other STDs may be
more prevalent and access to medical services or running
water may significantly alter the relationship between
circumcision and STDs including HIV infection.'19 Care should also be taken to ensure
that circumcision status is not a surrogate marker of
culturally-determined risk or health-care seeking
behaviour.

This work were supported by a Commonwealth AIDS
Research Grant. Our thanks to Professor Tony Cunningham,
Peter Field, and David Ho of the Virology Unit, Centre for
Infectious Diseases and Clinical Microbiology, Westmead Hospital
for performing serological tests for HSV.